Throat and Oral Cancers
(Buccal Cavity Carcinoma; Esophageal Cancer; Head and Neck Cancer, Upper Aerodigestive Tract Carcinoma)
Cancers of the upper aerodigestive tract, which extends from the mouth and nasal passages to the stomach, are relatively rare, especially when compared with malignancies of the colon and other lower digestive organs. But cancers arising anywhere in the mouth and throat are especially devastating because of their effect on appearance and the ability to eat.
Pharynx and Esophageal Cancers. The pharynx, the muscular structure that begins in the back of the mouth, and the esophagus, the tube that receives food from the pharynx and transports it to the stomach, are two common sites of cancer in the throat portion of the upper digestive tract. Each year, more than 9,000 cases of pharynx cancer and 12,000 cases of esophageal cancer are diagnosed, resulting in about 4,000 and 11,000 annual deaths respectively. (The larynx, another throat structure, is the site of about 12,000 new cancers a year, see page 267 for a more detailed discussion.)
Men with esophageal or pharynx cancer greatly outnumber women, but this situation is changing with the growing number of women who smoke -- the major cause of these cancers. The combination of smoking and heavy alcohol use seems to compound the risk. Less commonly, esophageal cancer is associated with iron deficiency anemia. Tylosis, a hereditary disease characterized by thickening of the palms and soles, is also linked to an increased incidence of esophageal cancer.
Difficulty in swallowing is the most common symptom suggesting throat cancer. Initially, the problem is confined mostly to solid foods, but eventually, swallowing even pureed foods or fluids may be difficult. Often, the person describes a feeling of a chronic lump in the throat, frequent spitting up of undigested food, and choking. There may also be a sore throat and possible voice changes as the tumor grows.
Oral Cancers. Each year, more than 19,000 Americans are diagnosed with oral cancer, which can develop in any of the structures in and around the mouth -- the tongue, cheeks, gums, lips, soft and hard palate, and other oral tissues. In recent years, a marked increase of oral cancer has occurred among young people, especially those who use chewing tobacco or snuff. Overall, tobacco users have 15 limes more oral cancer than nonsmokers, but the risk rises to more than 50-fold among those who use chewing tobacco and snuff. As with esophageal and throat cancers, the combination of alcohol and tobacco further increases risk. Pipe and cigar smokers have a higher-than-normal incidence of lip cancers.
Other contributing factors include nutritional deficiencies, which are rare in the United States; chronic mouth infections and poor dental hygiene may also contribute to the development of oral cancer. Excessive sun exposure carries a risk of lip cancer.
Oral cancers are easier to detect in an early stage than those that develop in the pharynx and esophagus. Any persistent sore on the lips, tongue, or soft tissue inside the mouth raises a suspicion of oral cancer. The development of white or red patches that don't go away and bleed easily calls for prompt medical investigation. There also may be painless swelling of the lymph nodes located in the neck.
Lip cancer may appear first as a growth, most often on the lower lip, that forms a dry crust which bleeds when removed and then crusts over again Cancer of the hard palate usually manifests itself as a persistent sore, which may ulcerate. All of the oral cancers can produce mild irritation and pain, which worsen as the cancer progresses. These pains may be felt eventually in or around the ear as well.
Diagnostic Studies and Procedures
A dentist is often the first to notice signs of oral cancer, especially patches of leukoplakia, a whitish lesion that is often precancerous, or erythroplakia, similar patches that are red. A doctor begins the diagnostic process with a physical examination that includes careful examination of the inside of the mouth and throat and palpating of the lymph nodes in the neck to check for swelling or a change in consistency. To diagnose oral cancer, however, a biopsy is necessary.
If esophageal cancer is suspected. X-rays will be taken, usually after the patient first swallows a liquid containing barium, a chalky substance that enhances the organs on film. Using a fluoroscope, a doctor can observe the motion and outline of the esophagus as the barium passes through it. Additional X-rays, taken once the esophagus is coated with barium, will reveal any abnormalities in its outline.
Esophagoscopy -- an examination in which a lighted tube with magnifying devices is inserted into the esophagus -- and a biopsy of suspicious tissue provide a definitive diagnosis.
After a doctor confirms the presence of cancer, additional tests are needed to determine the extent of the disease, a procedure called staging that is used to decide the most effective treatment approach. Staging usually requires additional X-rays and CT scans, blood tests, and perhaps ultrasound examination or other imaging studies of the liver, lungs, bones, and other organs.
Medical Treatments
Pharynx and Esophageal Cancers. Early pharynx cancer is highly curable by surgical removal of the tumor and a surrounding margin of healthy tissue, usually followed by radiation therapy. Depending upon the location of the cancer, this may require extensive neck surgery that affects both appearance and function. In some cases, the larynx must also be removed, even if the cancer has not spread to it.
Esophageal cancer is more difficult to treat because it is often quite advanced at the time of diagnosis. Surgery offers the best possibility of a cure, especially if the cancer is in the middle to lower segment of the esophagus. When all or most of the esophagus must be taken out. the uppermost portion of the stomach can be fashioned into a replacement food tube. If this is not feasible, a portion of the colon may be used.
In some cases, radiation is the primary treatment; in others, it is used as an adjunct to surgery or as a means of controlling pain and other symptoms when a cure is unlikely. Radiation must be administered carefully to avoid damaging the heart, spinal cord, and other vital structures.
Chemotherapy may be used, either alone or with radiation, to shrink a tumor before surgery.
Oral Cancers. Most oral cancers are treated surgically. Depending on the location of the cancer and its size, the operation can result in changes in appearance and difficulty in chewing, swallowing, and speaking, especially if the tongue is involved.
Fortunately, great strides in reconstructive plastic surgery have helped minimize the disfigurement and functional disabilities associated with oral cancer. Following treatment, skin, bone, and cartilage grafts may all be necessary. Internal prostheses can restore the teeth, palate, jawbone, and other structures inside the mouth. These devices are made by maxillofacial orthodontists, dentists who have special training in oral reconstruction.
Radiation is also used to treat oral cancers and is particularly effective in those detected at an early stage. It may be given either by external beam or by implanting radioactive seeds at the site of the tumor. In either approach, the overall objective is the same: to direct the cancer-killing radiation towards the tumor while sparing as much of the surrounding healthy tissue as possible.
Chemotherapy can be an effective method in reducing the size and density of certain types of tumors.
Alternative Therapies
Although alternative therapy cannot cure these cancers, some are useful in managing pain and in mitigating the symptoms and side effects of treatment. In particular, imaging, visualization, meditation, and other relaxation therapies are often employed.
Acupressure. You may be able to alleviate nausea associated with chemotherapy and radiation treatments by pressing on the middle of your inner wrists either manually or by wearing acupressure bracelets designed to prevent motion sickness.
Herbal Medicine. Ginger root is highly effective in preventing or minimizing nausea, a common complication of radiation treatments and chemotherapy. For some people, sipping flat ginger ale helps; others may respond to ginger capsules or tablets. Avoid chewing raw or candied ginger, however; these forms can further irritate and damage the lining of the mouth and esophagus among patients undergoing cancer therapy.
Nutrition Therapy. Oral and throat cancers often interfere with normal eating. A clinical nutritionist trained in treating patients with these cancers can devise a balanced diet of soft or liquid foods. Enriched liquid supplements may be needed; if treatment makes it impossible to swallow, feeding can be accomplished via a gastric tube inserted directly into the stomach through a small abdominal incision. Small, frequent meals of nutrient-rich liquids are poured into this tube. Medication can be given intravenously or in a liquid added to the gastric feedings.
Physical, Occupational, and Speech Therapy. Rehabilitation is essential after extensive head and neck surgery, especially when normal eating and speaking have become impaired. Rehabilitation usually involves a team of therapists who are trained in teaching patients new ways to eat, swallow, and speak. The team may also include a demist and plastic surgeon.
Psychotherapy. A potentially disfiguring oral cancer or an incurable esophageal cancer is likely to cause a patient great psychological distress. Some form of counseling or therapy is often recommended as part of the rehabilitation process. Support groups of people with similar problems are of special value because they usually provide both emotional support and practical tips for coping with the condition.
Self-Treatment
Oral and throat cancers develop slowly, and some experts believe that early preventive action may stop precancerous lesions from developing into invasive cancer. If you use tobacco in any form and notice white or red patches in your mouth, it is imperative that you stop the habit. Treatment at this stage, along with giving up tobacco, may prevent further progression.
If you've had surgical treatment for for oral or throat cancer, it can hinder your ability to eat normally. Consult a qualified nutritionist (see Nutrition Therapy) for guidance and eat frequent, small meals; pureed foods served cold or at room temperature are less likely to provoke nausea than warm foods.
Radiation therapy to the head and neck can reduce or even halt the flow of saliva, adding to eating problems. Drink extra fluids and ask your doctor to recommend an artificial saliva product. This therapy can also cause hair loss and increase the skins sensitivity to sunlight. Although the hair loss is usually temporary, it can be devastating, especially if surgery has already caused disfigurement. Investing in an attractive wig can boost morale; many insurance policies cover wigs, which are also tax deductible for people undergoing cancer treatment. To prevent sunburn, use a sunblock or wear protective clothing.
Maintaining oral hygiene during treatment is extremely important. Have a complete dental checkup before radiation therapy begins, and get instructions on caring for your teeth and gums. Radiation treatments can increase the likelihood of developing cavities, so you should see a dentist regularly and follow instructions on oral care.
Other Causes of Throat and Mouth Symptoms
Dental disease, recurrent canker sores, and irritation from a broken tooth, jagged filling, or ill-fitting dentures can produce symptoms that could be mistaken for those of oral cancer. Esophageal outpouches, or diverticula, as well as esophageal webs and chronic throat irritation or infections can cause swallowing problems and other symptoms that resemble those of pharynx or esophageal cancer.